Michael Chaim Sklar1,2, Fabiana Madotto1,3, Annemijn Jonkman1,4, Michela Rauseo1, Ibrahim Soliman1, L Felipe Damiani1,5, Irene Telias1, Sebastian Dubo1,6,7, Lu Chen1, Nuttapol Rittayamai1,8, Guang-Qiang Chen1, Ewan C Goligher1,2,9,10, Martin Dres1,11, Remi Coudroy1,12, Tai Pham1,13, Ricard M Artigas1, Jan O Friedrich1,2, Christer Sinderby1,2,14, Leo Heunks1,4, Laurent Brochard15,16. 1. Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 4th Floor, Room 411, 209 Victoria Street, Toronto, ON, M5B 1T8, Canada. 2. Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada. 3. Value Based Health-Care Unit, IRCCS Multimedica, Sesto San Giovanni, Milan, Italy. 4. Department of Intensive Care Medicine, Amsterdam UMC, Location VUmc, Amsterdam, The Netherlands. 5. Departamento de Ciencias de La Salud, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile. 6. Departamento de Kinesiologiá, Facultad de Medicina, Universidad de Concepción, Concepción, Chile. 7. Programa de Doctorado en Ciencias Médicas, Universidad de La Frontera, Temuco, Chile. 8. Division of Respiratory Diseases and Tuberculosis, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, 65106, Thailand. 9. Toronto General Hospital Research Institute, Toronto, ON, Canada. 10. Division of Respirology, Department of Medicine, University Health Network and Sinai Health System, Toronto, ON, Canada. 11. Pneumology and Critical Care Department, Public Assistance - Paris Hospital, Pitie-Salpetriere Hospital, Paris, France. 12. Médecine Intensive Réanimation, CHU de Poitiers, INSERM CIC1402 Alive Group, Université de Poitiers, Poitiers, France. 13. Service de Médecine Intensive-Réanimation, Hôpital de Bicêtre, Hôpitaux Universitaires Paris-Sud, Le Kremlin-Bicêtre, Paris, France. 14. Institute for Biomedical Engineering and Science Technology (iBEST), Ryerson University and St-Michael's Hospital, Toronto, Canada. 15. Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 4th Floor, Room 411, 209 Victoria Street, Toronto, ON, M5B 1T8, Canada. Laurent.Brochard@unityhealth.to. 16. Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada. Laurent.Brochard@unityhealth.to.
Abstract
BACKGROUND: In patients intubated for mechanical ventilation, prolonged diaphragm inactivity could lead to weakness and poor outcome. Time to resume a minimal diaphragm activity may be related to sedation practice and patient severity. METHODS: Prospective observational study in critically ill patients. Diaphragm electrical activity (EAdi) was continuously recorded after intubation looking for resumption of a minimal level of diaphragm activity (beginning of the first 24 h period with median EAdi > 7 µV, a threshold based on literature and correlations with diaphragm thickening fraction). Recordings were collected until full spontaneous breathing, extubation, death or 120 h. A 1 h waveform recording was collected daily to identify reverse triggering. RESULTS: Seventy-five patients were enrolled and 69 analyzed (mean age ± standard deviation 63 ± 16 years). Reasons for ventilation were respiratory (55%), hemodynamic (19%) and neurologic (20%). Eight catheter disconnections occurred. The median time for resumption of EAdi was 22 h (interquartile range 0-50 h); 35/69 (51%) of patients resumed activity within 24 h while 4 had no recovery after 5 days. Late recovery was associated with use of sedative agents, cumulative doses of propofol and fentanyl, controlled ventilation and age (older patients receiving less sedation). Severity of illness, oxygenation, renal and hepatic function, reason for intubation were not associated with EAdi resumption. At least 20% of patients initiated EAdi with reverse triggering. CONCLUSION: Low levels of diaphragm electrical activity are common in the early course of mechanical ventilation: 50% of patients do not recover diaphragmatic activity within one day. Sedatives are the main factors accounting for this delay independently from lung or general severity. Trial Registration ClinicalTrials.gov (NCT02434016). Registered on April 27, 2015. First patients enrolled June 2015.
BACKGROUND: In patients intubated for mechanical ventilation, prolonged diaphragm inactivity could lead to weakness and poor outcome. Time to resume a minimal diaphragm activity may be related to sedation practice and patient severity. METHODS: Prospective observational study in critically illpatients. Diaphragm electrical activity (EAdi) was continuously recorded after intubation looking for resumption of a minimal level of diaphragm activity (beginning of the first 24 h period with median EAdi > 7 µV, a threshold based on literature and correlations with diaphragm thickening fraction). Recordings were collected until full spontaneous breathing, extubation, death or 120 h. A 1 h waveform recording was collected daily to identify reverse triggering. RESULTS: Seventy-five patients were enrolled and 69 analyzed (mean age ± standard deviation 63 ± 16 years). Reasons for ventilation were respiratory (55%), hemodynamic (19%) and neurologic (20%). Eight catheter disconnections occurred. The median time for resumption of EAdi was 22 h (interquartile range 0-50 h); 35/69 (51%) of patients resumed activity within 24 h while 4 had no recovery after 5 days. Late recovery was associated with use of sedative agents, cumulative doses of propofol and fentanyl, controlled ventilation and age (older patients receiving less sedation). Severity of illness, oxygenation, renal and hepatic function, reason for intubation were not associated with EAdi resumption. At least 20% of patients initiated EAdi with reverse triggering. CONCLUSION: Low levels of diaphragm electrical activity are common in the early course of mechanical ventilation: 50% of patients do not recover diaphragmatic activity within one day. Sedatives are the main factors accounting for this delay independently from lung or general severity. Trial Registration ClinicalTrials.gov (NCT02434016). Registered on April 27, 2015. First patients enrolled June 2015.
Entities:
Keywords:
Critical care; Diaphragm; Electrical activity of the diaphragm; Mechanical ventilation; Sedation
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